Original Paper
Med Princ Pract 2016;25:169–175
DOI: 10.1159/000442416
Assessment of Third Molar Impaction Pattern
and Associated Clinical Symptoms in a Central
Anatolian Turkish Population
Selmi Yilmaz a Mehmet Zahit Adisen a Melda Misirlioglu a Serap Yorubulut b
a
Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, and b Department of Statistics,
Faculty of Science and Letters, Kırıkkale University, Kırıkkale, Turkey
Key Words
Third molar impaction · Winter’s classification · Pain ·
Pericoronitis · Turkish population
Abstract
Objectives: The purpose of this study was to assess the pattern
of third molar impaction and associated symptoms in a Central
Anatolian Turkish population. Material and Methods: A total
of 2,133 impacted third molar teeth of 705 panoramic radio-
graphs were reviewed. The positions of impacted third molar
teeth on the panoramic radiographs were documented ac-
cording to the classifications of Pell and Gregory and of Winter.
The presence of related symptoms including pain, pericoroni-
tis, lymphadenopathy and trismus was noted for every pa-
tient. Distributions of obtained values were compared using
the Pearson χ2 test. Nonparametric values were analyzed us-
ing the Mann-Whitney U test and Kruskal-Wallis test. Results:
The mean age of the subjects was 30.58 ± 11.98 years (range:
19–73); in a review of the 2,133 impacted third molar teeth, the
most common angulation of impaction in both maxillaries
was vertical (1,177; 55%). Level B impaction was the most com-
mon in the maxilla (425/1,037; 39%), while level C impaction
was the most common in the mandible (635/1,096; 61%). Pain
(272/705; 39%) and pericoronitis (188/705; 27%) were found
to be the most common complications of impaction. Among
© 2015 S. Karger AG, Basel
1011–7571/15/0252–0169$39.50/0
E-Mail karger@karger.com This is an Open Access article licensed under the terms of the
www.karger.com/mpp Creative Commons Attribution-NonCommercial 3.0 Un-
ported license (CC BY-NC) (www.karger.com/OA-license),
applicable to the online version of the article only. Distribu-
tion permitted for non-commercial purposes only.
Received: March 24, 2015
Accepted: November 12, 2015
Published online: November 13, 2015
705 patients (335 males, 370 females), pericoronitis was more
prevalent in males (101; 30%) and usually related to lower third
molars (236; 22%). The retromolar space was significantly
smaller in females (p < 0.05). Moreover, there was a significant
difference in retromolar space for the area of jaw (maxillary:
11.3 mm; mandibular: 14.2 mm) and impaction level (A: 14.7
mm; B: 11.1 mm; C: 10.3 mm; p < 0.05). Conclusion: The pattern
of third molar impaction in a Central Anatolian Turkish popula-
tion was characterized by a high prevalence rate of level C im-
paction with vertical position. Pain and pericoronitis were the
most common symptoms usually associated with level A im-
paction and vertical position. © 2015 S. Karger AG, Basel
Introduction
Tooth impaction is a pathological situation in which a
tooth cannot or will not erupt into its normal functioning
position [1]. In human dentition, the third molars have
the highest impaction rate of all teeth [1]. The major fac-
tors related to tooth impaction are lack of space, limited
skeletal growth, increased crown size and late maturation
of the third molars [2]. Although impacted third molars
may remain symptom free indefinitely, they could give
cause for various symptoms and pathologies, such as
Dr. Mehmet Zahit Adısen
Department of Oral and Maxillofacial Radiology
Faculty of Dentistry, Kırıkkale University
TR–71450 Kırıkkale (Turkey)
E-Mail m_zahit @ hotmail.com

Level A
Fig. 1. Pell and Gregory classification. Level A: the occlusal plane of
the impacted tooth is at the same level as the occlusal plane of the
second molar (the highest portion of the impacted third molar is on
a level with or above the occlusal plane); level B: the occlusal plane
of the impacted tooth is between the occlusal plane and the cervical
Mesioangular
80
Horizontal
Fig. 2. Winter’s classification. Vertical im-
paction: the long axis of the third molar is
parallel to the long axis of the second molar 100
(from 10 to –10°); mesioangular impac-
tion: the impacted tooth is tilted toward the
second molar in a mesial direction (from
11 to 79°); horizontal impaction: the long
axis of the third molar is horizontal (from
80 to 100°); distoangular impaction: the
long axis of the third molar is angled dis-
tally/posteriorly away from the second mo-
lar (from –11 to –79°); others (from 101 to
–80°).
pericoronitis, pain, swelling, distal caries, bone loss, root
resorption of adjacent teeth, odontogenic cysts and tu-
mors [3]. It is considered that the occurrence of pathol-
ogy resulting from impaction has a multifactorial origin
[4]. Eruption status, position and angulation have an im-
pact on these symptoms [4]. The decision whether or not
to remove a mandibular third molar is probably one of
the most frequent treatment decisions in the dental pro-
fession [3, 5, 6]. Hashemipour et al. [7] had noted that the
anatomical position of impacted third molars shows im-
170 Med Princ Pract 2016;25:169–175
DOI: 10.1159/000442416
Color version available online
Level B Level C
margin of the second molar (the highest portion of the impacted
third molar is below the occlusal plane but above the cervical line of
the second molar); level C: the impacted tooth is below the cervical
margin of the second molar (the highest portion of the impacted
third molar is below the cervical line of the second molar).
Color version available online
10 Vertical –10
Distoangular
–80
180
portant variations which anticipate difficulty of extrac-
tion. Several methods have been used to classify impac-
tion [4]. This classification is based on many factors,
which are the level of impaction, the angulation of the
third molars and the relationship to the anterior border
of the ramus. The depth or level of maxillary and man-
dibular third molars can be classified using the Pell and
Gregory classification system, where the impacted teeth
are assessed according to their relationship to the occlusal
surface of the adjacent second molar [2].
Yilmaz/Adisen/Misirlioglu/Yorubulut
 Color version available online
Fig. 3. Retromolar space measurements on panoramic radiogra-
phy (red double-headed arrows; colors in the online version only):
a = line from the anterior limit of the mandibular ramus; b = line
from the posterior limit of the maxillary second molar; c = line
from the posterior limit of the mandibular second molar.
In previous studies on the Turkish population, the im-
pacted molars were examined retrospectively using only
radiological findings that included caries, bone loss and
periodontal damage [3], or the clinical symptoms were
evaluated only by comparing the status of eruption [8].
Hence, the aim of this study was to assess the third molar
impaction pattern comprehensively by examining the
status of eruption and angulation on panoramic radio-
graphs and relating them to the associated clinical symp-
toms in a Central Anatolian Turkish population.
Material and Methods
A retrospective study was made of 705 patients (335 males and
370 females) with at least 1 impacted third molar detected on pan-
oramic radiography at the Department of Oral and Maxillofacial
Radiology from February to August 2014. The study plan was ap-
Third Molar Impaction Pattern and
Associated Symptoms
proved by the administration of the Faculty of Dentistry. Exclusion
criteria were records of patients aged <19 years with any patho-
logical dentoalveolar condition, any craniofacial anomaly or syn-
drome such as Down syndrome, cleidocranial dysostosis or the
presence of incomplete records or poor-quality orthopantomo-
grams, incomplete root formation of third molars or absence of
adjacent second molars, a history of any dental extraction or orth-
odontic treatment. When reviewing panoramic radiographs, clin-
ical records of patients were also examined, and related symptoms
including pain, pericoronitis, lymphadenopathy (LAP) and tris-
mus were noted for every patient. All impacted third molar teeth
on panoramic radiographs were reviewed by a single examiner
(S.Y.) using a Cliniview 10.0.2 (Instrumentarium, Tuusula, Fin-
land) X-ray viewer to determine the levels of eruption and angula-
tions. In order to minimize the risk of false assessments caused by
fatigue, no more than 50 radiographs were evaluated at a time. The
depth of impacted lower third molars in relation to the occlusal
plane was recorded according to the classification of Pell and Greg-
ory (fig. 1). The angulation of an impacted third molar was docu-
mented based on Winter’s classification with reference to the angle
formed between the intersected longitudinal axes of the second
and third molars (fig. 2). The distance from the ramus to the distal
surface of the second molar (retromolar space) was also measured
(fig. 3).
Distributions of obtained values were compared using a Pear-
son χ2 test, using the Statistical Package for the Social Sciences 22
software. Distribution of retromolar space was tested for normal-
ity using Kolmogorov-Smirnov and Shapiro-Wilk tests. When the
retromolar space was not found to be normally distributed (p <
0.05), the Mann-Whitney U test was used to compare 2-group
variables. The Kruskal-Wallis test and pairwise comparisons were
used to compare 3-group variables. One hundred panoramic ra-
diographs were re-evaluated after an interval of 1 week to measure
intraexaminer error. The Cohen kappa coefficient was found to be
91%.
Results
Of the 705 patients (mean age: 30.58 ± 11.98 years,
range: 19–73) with at least 1 impacted third molar tooth,
335 (47.5%) were males and 370 (52.5%) were females;
the difference was not statistically significant (p = 0.187).
From the 705 patients, a total of 2,133 impacted third
molar teeth was examined – maxilla: 1,037 (49%) and
mandible: 1,096 (51%) –, and the difference was not sta-
tistically significant either (p = 0.201). The distribution
of third molars by level of impaction and angulation is
shown in table 1. The most common angulation of im-
paction in both maxillae and mandibulae was vertical.
Level B impaction was the most common in the maxilla
(425; 39%), while level C impaction was the most com-
mon in the mandible (635; 61%). The distribution of
symptoms by gender and area of jaw is shown in table 2.
Pain (272; 39%) and pericoronitis (188; 27%) were the
Med Princ Pract 2016;25:169–175 171
DOI: 10.1159/000442416
Table 1. Distribution (numbers, percentages in parentheses) of third molar impaction by level of impaction and angulation

Level of impaction Angulation

A B C p value M D V H O p value

Maxillary impacts 272 (25) 425 (39) 399 (36) <0.01* 96 (9) 343 (33) 592 (57) 5 (0.5) 1 (0.1) <0.01*
Mandibular impacts 210 (20) 192 (19) 635 (61) 313 (29) 144 (13) 585 (53) 53 (5) 1 (0.1)
Total 482 (23) 617 (29) 1,034 (48) 409 (19) 487 (23) 1,177 (55) 58 (3) 2 (0.1)

* p < 0.05: statistically significantly different. M = Mesioangular; D = distoangular; V = vertical; H = horizontal; O = other.

Table 2. Distribution (numbers, percentages in parentheses) of symptoms by gender and area of jaw

Gender Area of jaw

male female total p value maxillary mandibular total p value
(n = 335) (n = 370) (n = 705) impacts impacts (n = 2,133)
(n = 1,037) (n = 1,096)

Pain 131 (39) 141 (38) 272 (39) 0.786 404 (39) 447 (41) 851 (40) 0.389
Pericoronitis 101 (30) 87 (24) 188 (27) 0.027* 16 (2) 236 (22) 252 (12) <0.001*
LAP 47 (14) 41 (11) 88 (12) 0.237 132 (13) 159 (15) 291 (14) 0.232
Trismus 36 (11) 35 (9) 71 (10) 0.571 103 (10) 125 (11) 228 (11) 0.271

* p < 0.05: statistically significantly different.

Table 3. Distribution (numbers, percentages in parentheses) of symptoms by level of impaction and angulation

Level of impaction Angulation

A B C p value M D V H p value

Pain 318 (37) 280 (33) 253 (30) <0.01* 173 (20) 240 (28) 408 (48) 30 (4) <0.01*
Pericoronitis 112 (44) 107 (42) 33 (14) <0.01* 75 (30) 64 (25) 101 (40) 12 (5) <0.01*
LAP 112 (38) 88 (30) 91 (32) <0.01* 61 (21) 75 (26) 148 (51) 7 (2) <0.01*
Trismus 87 (38) 84 (37) 57 (25) <0.01* 42 (18) 71 (31) 107(47) 8 (4) <0.01*

* p < 0.05: statistically significantly different. M = Mesioangular; D = distoangular; V = vertical; H = horizontal.

most common complications of impaction, followed by
LAP (88; 12%) and trismus (70; 10%). There was no sig-
nificant difference in frequency of pain, LAP and trismus
between genders and areas of jaw. Pericoronitis was
more prevalent in males (101; 30%) than females and was
usually related to lower third molars (236; 22%). The dis-
tribution of symptoms showed significant differences by
level of impaction and angulation (p < 0.01), as presented
in table  3. The occurrence rate of symptoms showed
higher percentages for pain (318; 37%), pericoronitis
(112; 44%), LAP (112; 38%) and trismus (87; 38%) at lev-
el A impaction than other impaction levels. Also it was
noted that most of the symptoms of pain (408; 48%),
pericoronitis (101; 40%), LAP (148; 51%) and trismus
(107; 47%) were associated with vertically angulated
third molars. The retromolar space was significantly
smaller in females (13.8 mm) than males (11.9 mm; p <
0.05). Moreover there was a significant difference in ret-
romolar space for the area of jaw (maxillary: 11.3 mm;
mandibular: 14.2 mm) and impaction level (A: 14.7 mm;
B: 11.1 mm; C: 10.3 mm; p < 0.01; table 4). Pairwise com-
parisons indicated that the retromolar space showed dif-
ferent results for impaction levels (table 5).

172 Med Princ Pract 2016;25:169–175 Yilmaz/Adisen/Misirlioglu/Yorubulut

DOI: 10.1159/000442416
Table 4. Means and SD of retromolar space (mm) by gender, area al. [4] from Spain reported level B as the most common
of jaw and level of impaction position of mandibular third molars. These differences in
angulation and level of impaction could be due to the dif-
Mean SD p value
ference in race, patient selection criteria and study popu-
Gender <0.01* lation. Hereof Richardson [16] and Ventä et al. [17] sug-
Male 13.8 5.63 gested that it would be inaccurate to predict the eruption
Female 11.9 2.85 or impaction of third molars before the age of 20 years
Area of jaw <0.01* because of continuous positional changes during further
Maxillary 11.3 4.41
Mandibular 14.2 2.65
development.
Level of impaction <0.01* Pericoronitis is a soft tissue infection located around
A 14.7 2.12 the crown of a partially impacted tooth, whose appearance
B 11.1 3.14 implies the accumulation of microorganisms and food re-
C 10.3 1.86 mains [4]. The impact of gender on the development and
Gender and area of jaw assessed by the Mann-Whitney U test,
frequency of pericoronitis has been reported in the litera-
level of impaction by the Kruskal-Wallis test. * p < 0.05: statisti- ture. In the present study, we found a slight tendency in
cally significantly different. male patients for pericoronitis, but other symptoms
showed no gender predominance. In contrast, Bataineh et
al. [9] reported that pericoronitis cases were much more
frequently seen in female patients than male patients.
Likewise Yamalık and Bozkaya [18] found a predomi-
Table 5. Pairwise comparisons of impaction levels for the retromo-
lar space
nance of females for pericoronitis. However, Almendros-
Marqués et al. [4] and Akarslan and Kocabay [2] found no
Comparison Test Standard Standard p value Adjusted gender predominance for all complaints and pathologies.
groups statistics error test p value The finding of a higher prevalence rate of pericoronitis
statistics
for impacted third molars in this study confirmed the
C-B 564.601 31.245 18.070 <0.001* <0.001* previous studies of Jamileh and Pedlar [19] and Khawaja
C-A 1,021.125 34.374 29.706 <0.001* <0.001* [20] that pericoronitis was the most common indication
B-A 456.524 38.165 11.962 <0.001* <0.001* for removal of impacted mandibular third molars. A
probable explanation could be that pericoronitis is a com-
* p < 0.05: statistically significantly different. mon pathological condition of the mandibular impacted
teeth.
In the present study, the observation that angulation
had a statistically significant impact on the development
Discussion of pericoronitis and other clinical symptoms confirmed
that vertical angulation was an important factor for the
This study showed a high prevalence rate of third mo- development of clinical symptoms. As previously sug-
lar impaction in the vertical position. This finding con- gested, Leone et al. [21] had reported that the third molars
firmed the previous studies of Almendros-Marqués et al. which were most likely to cause pericoronitis were verti-
[4], Bataineh et al. [9] and Hugoson and Kugelberg [10], cal and slightly distoangular teeth. On the other hand, in
who had reported that the most common angulation was the studies of Güngörmüs [22] and Kay [23] the majority
vertical. However, other studies had shown that the most of pericoronitis cases were reported to be involved with
common type was mesioangular impaction [11, 12]. The mesioangular impactions. Eventually, Polat et al. [3] sug-
level of impaction assessed based on the Pell and Gregory gested that most molars with pathoses were either in a
classification showed that level B impaction was the most vertical or in a mesioangular position, but this is because
common in the maxilla, similar to the study of Hassan [1], such positions have a higher frequency. In this regard,
while that of level C was the most common in the man- Murad et al. [24] suggested that these differences may be
dible. These findings conflict with most of the previous due to geographical variation related to diet.
studies that identified the most common position as level The eruption level of third molars has also an impact
A [7, 13, 14]. Further results also conflict with Blondeau on the development of clinical symptoms. In our study we
and Nach [15] from Canada, and Almendros-Marqués et observed that most of the impacted molars with pericoro-

Third Molar Impaction Pattern and Med Princ Pract 2016;25:169–175 173
Associated Symptoms DOI: 10.1159/000442416
nitis had erupted to the same level as the adjacent second
molar occlusal plane. Similar to our results, Halverson
and Anderson [25] reported an association of pericoroni-
tis with the third molar tooth at or below the height of the
occlusal plane of the arch. Leone et al. [21] suggested a
similar association with the third molar tooth at or above
the occlusal plane. Ali et al. [26] suggested that these
depths are generally associated more frequently with soft
tissue impaction, forming a cuff over partially erupted
teeth and starting pericoronitis.
Third molars are the teeth that most commonly follow
an abortive eruption path and become impacted. Lack of
space seems to be the major cause of abortive eruption.
However, eruption cannot be guaranteed despite ade-
quate space available in the jaw [27]. The development of
space for the third molar is governed by many factors,
including resorption of bone from the anterior border of
the ramus, backward slope of the anterior border of the
ramus in relation to the alveolar border, forward move-
ment of the dentition, growth in length of the mandible
and sagittal direction of mandibular growth [28]. In the
present study, we found a significant difference in retro-
molar space for levels of impaction. Also the retromolar
space seemed to decrease while the impaction level was
increased. In accordance with our finding, Björk et al.
[29] reported that the space behind the second molar was
reduced in 90% of cases with mandibular third molar im-
paction. Ganss et al. [30] reported that when the retromo-
lar space is 13.9 mm in women and 14.3 mm in men, the
probability of eruption is 70%. Later on, Ventä et al. [17]
stated that if the retromolar space is at least 16.5 mm, the
probability of eruption is 100%. With reference to these
studies and our results, we can suggest that third molar
teeth may be impacted if the retromolar space is lower
than 13.8 mm for males and 11.9 mm for females in the
Turkish population.
Conclusion
The pattern of third molar impaction in a Central Ana-
tolian Turkish population was characterized by a high
prevalence rate of level C impaction with vertical posi-
tion. Pain and pericoronitis were the most common
symptoms usually associated with level A impaction and
vertical position. Male patients with an impacted lower
third molar had a tendency to develop pericoronitis. The
retromolar space influenced the impaction level.

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